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General NPI Number Information
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NPI Number | 1093101784
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Entity Type | Organization
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Legal Business Name | ISLAND LIFE MD LLC
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Dates
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Enumeration Date | 04/09/2015
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Last Update Date | 04/09/2015
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Provider Practice Location Address
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Address Line | 9970 CENTRAL PARK BLVD N SUITE 102
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City | BOCA RATON
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State | FL
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Zip | 33428-2231
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Country | US
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Telephone | 561-430-3599
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Fax | 561-430-3529
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Provider Business Mailing Address
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Address Line | 1015 SPANISH RIVER RD APT 202
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City | BOCA RATON
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State | FL
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Zip | 33432-7607
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Country | US
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Telephone | 215-740-5746
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DOMINIK CHRZAN
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Credential | MD
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Telephone | 215-740-5746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME117139
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License Number State | FL
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